Medicare Promoting Interoperability Program for Eligible ...

1 Medicare Promoting Interoperability Program for Eligible Hospitals and Critical Access Hospitals Objectives and Measures for the EHR 2022 Reporting Period The following information is for Eligible hospitals and critical access hospitals (CAHs) attesting to CMS for their participation in the Medicare Promoting Interoperability Program in 2022. Objective Public Health and Clinical Data Exchange Required Measure electronic case Reporting The Eligible hospital or CAH is in active engagement with a public health agency (PHA) to submit case reporting of reportable conditions. Exclusion Any Eligible hospital or CAH meeting one or more of the following criteria may be excluded from the case reporting measure if the Eligible hospital or CAH: I. Does not treat or diagnose any reportable diseases for which data is collected by their jurisdiction's reportable disease system during the electronic health record (EHR) reporting period.

2 II. Operates in a jurisdiction for which no PHA is capable of receiving electronic case reporting data in the specific standards required to meet the certified electronic health record technology (CEHRT) definition at the start of the EHR reporting period; or III. Operates in a jurisdiction where no PHA has declared readiness to receive electronic case reporting data as of six months prior to the start of the EHR reporting period. Definition of Terms Active Engagement: Means that the Eligible hospital or CAH is in the process of moving towards sending "production data" to a PHA or clinical data registry (CDR), or is sending production data to a PHA or CDR. Active Engagement Option 1: Completed Registration to Submit Data: The Eligible hospital or CAH registered to submit data with the PHA or, where applicable, the CDR to which the information is being submitted; registration was completed within 60 days after the start of the EHR reporting period; and the Eligible hospital or CAH is awaiting an invitation from the PHA or CDR to begin testing and validation.

3 This option allows Eligible hospitals or CAHs to meet the measure when the PHA or the CDR has limited resources to initiate the testing and validation process. Eligible hospitals or CAHs that have registered in previous years do not need to submit an additional registration to meet this requirement for each EHR reporting period. Medicare Promoting Interoperability Program 1. Active Engagement Option 2: Testing and Validation: The Eligible hospital or CAH is in the process of testing and validation of the electronic submission of data. Eligible hospitals or CAHs must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within an EHR reporting period would result in that Eligible hospital or CAH not meeting the measure. Active Engagement Option 3: Production: The Eligible hospital or CAH has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.

4 Production Data: Refers to data generated through clinical processes involving patient care, and it is used to distinguish between data and test data which may be submitted for the purposes of enrolling in and testing electronic data transfers. Reporting Requirements YES/NO - The Eligible hospital or CAH must attest YES to being in active engagement with a PHA to submit case reporting of reportable conditions. The EHR reporting period in 2022 for new and returning participants attesting to CMS is a minimum of any continuous 90-day period within the calendar year. Eligible hospitals and CAHs are required to report on the following four measures under the Public Health and Clinical Data Exchange objective: Immunization Registry Reporting, Syndromic Surveillance Reporting, electronic case Reporting, and electronic Reportable Laboratory Reporting. Scoring Information Total points available for attesting to the four required measures: 10 points.

5 If an Eligible hospital or CAH is able to claim an exclusion for three or fewer of the four required measures, 10 points will be granted for the Public Health and Clinical Data Exchange objective if they report YES for one or more of the measures and claim applicable exclusions for which they qualify for the remaining measures. If applicable exclusions for all four required measures are claimed, then the 10 points will be redistributed to the Provide Patients electronic Access to their Health Information measure. 100 total points will be available for the required objectives and measures of the Medicare Promoting Interoperability Program . In order to earn a score greater than zero, an Eligible hospital or CAH must complete the activities required by the Security Risk Analysis and SAFER Guides1 measures, submit their complete numerator and denominator or Yes/No data for all required measures, attest to the Actions to limit or restrict the compatibility or Interoperability of CEHRT statement, as well as report on the required electronic clinical quality measure data.

6 1 The SAFER, or Safety Assurance Factors for EHR Resilience, Guides measure was added in the FY. 2022 Hospital Inpatient Prospective Payment Systems (IPPS) for Acute Care Hospital and Long-Term Care Hospital (LTCH) Prospective Payment System (PPS) Final Rule but will not affect Medicare Promoting Interoperability Program participants' total scores in 2022. Medicare Promoting Interoperability Program 2. Failure to report at least a 1 in all required measures with a numerator or reporting a No . for a Yes/No response measure (except for the SAFER Guides measure2) will result in a total score of 0 points for the Medicare Promoting Interoperability Program . Such Eligible hospitals or CAHs who fail to achieve a minimum total score of 60 points are not considered meaningful users and may undergo a downward payment adjustment. Rounding: When calculating the performance rates and measure and objective scores, scores will be rounded to the nearest whole number.

7 Additional Information In 2022, Eligible hospitals and CAHs may use technology meeting the existing 2015 Edition certification criteria, the 2015 Edition Cures Update criteria, or a combination of the two in order to meet the CEHRT definition. To learn more about the 2015 Edition Cures Update and the changes to 2015 Edition certification criteria finalized in the 21st Century Cures Act final rule (85 FR 25642), we encourage hospitals to visit cures-update. To check whether a health IT product that has been certified to the 2015 Edition Cures Update criteria, visit the Certified Health IT Product List (CHPL) at 2015 Edition or 2015 Edition Cures Update functionality must be used as needed for a measure action to count in the numerator during an EHR reporting period. However, in some situations the product may be deployed during the EHR reporting period but pending certification. In such cases, the product must be certified to the 2015 Edition or 2015 Edition Cures Update criteria by the last day of the EHR reporting period.

8 If PHAs have not declared six months before the start of the EHR reporting period whether the registry they are offering will be ready on January 1 of the upcoming year for use by providers seeking to meet EHR reporting periods in that upcoming year, an Eligible hospital or CAH can claim an exclusion. Eligible hospitals or CAHs that have previously registered, tested, or begun ongoing submission of data to a registry do not need to restart the process. The definition of jurisdiction is general, and the scope may be local, state, regional or at the national level. The definition will be dependent on the type of registry to which the provider is reporting. A registry that is borderless'' would be considered a registry at the national level and would be included for purposes of this measure. For more information from PHAs on the local implementation guides, which programs and implementation guides are supported, contact information, and more, please visit Interoperability .

9 A Certified Health IT Developer may certify to 45 CFR (f)(5) by providing documentation of electronic case reporting implementation using the eCR Now FHIR. application implementation guide to its ONC-Authorized Certification Body. For further 2 In 2022, Eligible hospitals and CAHs will be required to submit one yes/no attestation statement for completing an annual self-assessment using all nine SAFER Guides, but the yes or no attestation response will not affect participants' total scores. Medicare Promoting Interoperability Program 3. information, see electronic - case -reporting. Regulatory References The measure's objective may be found in Title 42 of the Code of Federal Regulations at (e)(8)(i). For further discussion, please see 83 FR 41634 through 41677. In order to meet this measure, an Eligible hospital or CAH must use technology certified to the criterion at 45 CFR (f)(5). Certification Criteria Below are the corresponding certification criteria for EHR technology that support this measure.

10 Certification Criteria (f)(5) Transmission to public health agencies electronic case reporting Medicare Promoting Interoperability Program 4.